Dr Azhar Mahmood Emergency Medicine Fellow George Washington University,USA

1. ACUTE APPENDICITIS
Dr. Azhar Mahmood
Emergency Medicine

2.  61YEAR OLD MALE NORMOTENSIVE,NON DIABETIC CAME INTHE NIGHT
SHIFT WITH FEVER AND PAIN IN RIF REGION SINCE 1 DAY.PATIENTWAS
RESTLESSAND ANXIOUS. VOMITING 2 EPISODES. HIS HAND WAS ONTHE
RIGHT LOWER QUADRAN. HEMODYANAMICALLY STABLE
 PATIENT HAD COMETO ED SOME DAYS AGO WITH COMPLAINTS OF PAIN
UPPERABDOMEN AND LEFT FLANK. PATIE NT HAD HISTORY OF
NEPHROLITHIASIS. PATIENT WAS ADVISED ADMISSION,HOWEVER HIS
PAIN SUBSIDED HE LEFT WENT LAMA.TLCWAS 7900. ED DOCTORS HAD
GIVEN URO AS WELL AS SURGERY FOLKLOW UP.
TODAY MORNING HE WAS SEEN IN OPD AND UROLOGIST ADVISES CT
KUB AND CBC. CT WAS SUGESTIVE OF APPENDICULAR LUMP AND TLC
WAS 14900.
PATIENT WAS ADVISED URGENT ADMISSION UNDER SURGERY BUT WENT
HOME AGAIN.
PATIENT WAS ADMITTED AND WAS CONERVATIVELY MANAGED BY
SURGERY DEPARTMENT.

3.  Abdominal pain – features will point you towards diagnosis
 SOCRATES
 Site and duration
 Onset – sudden vs gradual
 Character – colicky, sharp, dull, burning
 Radiation – e.g. Into back or shoulder
 Timing – constant, coming and going
 Exacerbating and alleviating factors
 Severity
 2 other useful questions about the pain:
 Have you had a similar pain previously?
 What do you think could be causing the pain?

4.  Appendicitis refers to inflammation of the
vermix appendix
 A blind ended muscular tube attached to
the posteromedial wall of the
caecum,about 2 cm below the ileo-caecal
junctio

5.  length = Avg 10 cms ,
Position = the base of the appendix is constant, being found at
the confluence of the three taeniae coli of the caecum, which fuse
to form the outer longitudinal muscle coat of the appendix.
 Arterial supply = Appendicular artery branch of Ileo colic artery
branch of superior mesentric artery
Venous drainage = Appendicular veins drain into ilio colic veins –
Inferior mesentric veins
 Lymphatics vessels = Ileocaecal lymphnodes
Nerve supply =parasympathetic is vagus. SympatheticT10
Suspended by peritoneal fold..Mesoappendix
 Functions = maturation of B lymphocytes
Integral part of GALT (gut associated lymphoid tissue)

10. Between 250,000 and 300,000
appendectomies for acute appendicitis are
performed each year in the United States
Most common in patients aged 10 to 19
years
Incidence is 1.4 times greater in men
Most frequent cause of atraumatic
abdominal pain in children >1 year old
 Most common nonobstetric surgical
emergency in pregnancy, complicating up to 1
in 1500 pregnancies

11. First described by Reginald Fitz in 1886
American Dr.Thomas Morton performed the
first appendectomy for appendicitis
successfully in 1887
 First performed laparoscopically by German
Kurt Semm in 1981
 Laparoscopic procedure was rejected
originally as “unethical,” but quickly became
mainstream.

12. 1.The overall mortality rate of 0.2-0.8% is attributable to
complications of the disease rather than to surgical
intervention
2.Mortality rate rises above 20% in patients older than 70
years, primarily because of diagnostic and therapeutic delay
3.Perforation rate is higher among patients younger than 18
years and patients older than 50 years, possibly because of
delays in diagnosis
.
4.Appendiceal perforation is associated with an increase in
morbidity and mortality rates

13. Obstructive causes- faecolith or stricture
Lymphatic Tissue
Gallstone
 Intestinal parasites – OxyurisVermicularis(pin
worm)
Tumour( Ca of the Caecum) in elderly & middle
age.
Fibrotic stricture of the appendix

14.  Bacteria
Calcium phosphate
Epithelial Debris
Inspissated fecal material
Foreign bodies ( Rarely)

15. PATHOPHYSIOLOGY

17. The signs and symptoms of acute appendicitis lie along a
spectrum that correlates with pathophysiology.
Accuracy of diagnosis entitles recognition and removal of
the inflamed appendix prior to perforation with a minimal
number of negative appendectomies

19.  general malaise, indigestion, or bowel
irregularity.
 Anorexia is common but not universally
present
 Alterations in bowel function are highly
variable and can include constipation,
diarrhea, and even obstruction as a late
complication

20. Classically Pain starts in para umbilical area then shift to
RLQ. Pain in start is the somatic pain, mid gut pain.
Shifting is due the local irritation of anterior abdominal
wall at RIF.
dull ..continous …increase with the changes of position or
coughing or straining
Pain may be masked with the pain killers.
Atypical cases
Pain may start in the RIF, LIF , hypogastrium, right lumber
region, right hypochondrium. It depends upon the
position of caecum and tip of appendix.
CAUTION
sudden remittance of pain; consider appendiceal perforation

21.  There may be only nausea or anorexia
If nausea develops, it typically follows the
onset of pain.
Vomiting may or may not be present.
Subjective or objective fever is frequent.

22. Fever is in 50 to 70% of cases.
It is mild (up to 100’C ) in the early
stages but may be high grade after
rupture of appendix or pus formation.

23.  Loose motions.
 Burning micturition.
 Tenesmus.
 Painfull movements of right hip joint.
 Costovertebral tenderness, and percussion of
the right heel or shaking of the hospital
stretcher may elicit abdominal pain.

24.  TACHYCARDIA
 HYPERTHERMIA
FURREDWHITISHTOUNGE
TENDERNESS AT RIF
REBOUNDTENDERNESS AT RIF

28. • Dunphy’s sign Pain at RIF on coughing. It can differentiate
between the intraperitoneal and extra peritoneal organs
pathology.
• Rovesign sign Pain in RIF on deep palpation at LIF. It is
due to the movement of intestines towards RIF and touch
the inflamed appendix. It also differentiate between
intraperitoneal and extra peritoneal pathology.
•Pt unable to stand straight up due to spasm in the
ileopsoas muscles.
• Rectal and vaginal examination are crucial in the pelvic
appendix.
• Caecal gurgle is important sign in the retrocaecal
appendix

29. MANTRELS

30. D/D

32. .
PID can present with the symptoms indistinguishable from those of
appendicitis.Cervical motion tenderness and milky discharge
strengthened the diagnosis of PID. Pain is bilateral.Trans vaginal
ultrasound is very helpful to locates the tubo-ovarian abscess.
ECTOPIC PREGNANCY needs to be rule out in all female patients of
child bearing age.A positive pregnancy test should prompt the
ultrasound investigation.
OVRIAN CYST. can have mild to severe pain. It can be ruled out on
ultrasound.
OVARIANTORSION patient with twisted organ can have fever,
leukocytosis and pain in RIF. Ovarian torsion can be confirmed on
Doppler ultrasound.
Mittelschmerz midcycle rupture of a follicular cyst with bleeding
PEDIATRIC PATIENTS—Henoch Schonlein purpura, Mesentric
Lymphadenitis,Meckel’s Diverticulum.

33. PYELONEPHRITIS patients can have fever,
vomiting, rigors, costovertebral pain and
tenderness. Diagnosis can be confirmed by urine
analysis and ultrasound.
URETERIC COLIC pain and vomiting are the
common feature but tenderness is minimal.
Hematuria suggest the diagnosis which can be
confirmed on US and urine analysis.

34. GASTROENTERITIS nausea and vomiting start before pain along with fever, diarrhea and
poorly localized abdominal pain and tenderness.WBC count is often normal in
gastroenteritis.
MECKEL DIVERTICULUM present with symptoms and signs indistinguishable from those
of appendicitis, but it characteristically occurs in infants.Testicular torsion pain start in RLQ
and the local tenderness.
MESENTERIC LYMPHADENITIS usually occurs in patients younger than 20 years old and
present with middle, followed by RLQ abdominal pain but without tenderness or guarding.
TYPHLITIS characterized by inflammation of wall of caecum.
Peptic ulcer disease
Diverticulitis
Cholecystitis.

35.  WBC earliest marker of inflammation
 a normalWBC is not uncommon, and
leukopenic presentations have been
documented
 does not distinguish between simple and
perforated appendicitis
 C-reactive protein and the erythrocyte
sedimentation rate used alone lack the
sensitivity and specificity

36.  urinalysis : because isolated microscopic
hematuria may support a diagnosis of renal
colic, and pyuria may suggest pyelonephritis.
However, hematuria or sterile pyuria can be
present in acute appendicitis.
 pregnancy test in females of reproductive
age to rule out ectopic or heterotopic
pregnancy

37.  poor sensitivity and specificity.
only value of radiographs is to assess for other causes of the
patient’s symptoms, such as bowel obstruction or bowel
perforation.
An ileus mimicking bowel obstruction may occur in
appendicitis due to peritoneal inflammation, and advanced
appendicitis may perforate, resulting in intraperitoneal air on an
abdominal radiograph

38. Graded compression Sonography is relatively inexpensive, rapid,
noninvasive, and requires no patient preparation or contrast material
administration.
 USG is helpful or necessary to rule out the important differential
diagnosis like renal, gynecological and hepatic conditions.
 Inflamed appendix is non-compressible tubular structure, more than 6
mm in diameter, with a thickened wall.
 Sensitivity 78% • Specificity 92% • Accuracy 87%
 Limitations:
Operator dependent.
Patient cannot be send home after negative result.

39. A noncompressible, inflamed
appendix is shown in a cross-
sectional view
longitudinal section of the
swollen appendix in early
stages
An appendicolith with acoustic
shadowing

40.  Highly sensitive and specific
Typical CT findings of an inflamed appendix is a thickened wall and a nonfilling
appendix associated with peri-appendicular inflammatory fluid.
Highly sensitive for the complications developed due to appendicitis.
It is highly sensitive for the complications developed due to appendicitis.
It helps us in the decision of time of intervention.
Helical CT has Sensitivity 90-100% Specificity 91-99%Accuracy 94-98%
CT scanning of patients with suspected appendicitis may reduce the number of
patients admitted for observation and decrease the rate of negative
appendectomy

42.  Used in children and pregnant women as it
has negligible radiation toxicity.
In the first trimester its use is still not
recommended as fetus is still in the phase of
organogenesis

44.  Several surgeons have advocated the use of
laparoscopy as a diagnostic modality in the
evaluation of a patient suspected of having
acute appendicitis.
 It is more preferable in female patients or in
the doubtful cases. Secondly if there is inflamed
appendix then it can be removed during the
same procedure

46. IF SIMPLE APPENDICITIS OPEN /LAP
IF PERFORATED EXPLORATORY LAP,APPENDECTOMYAND
PERITONEALTOILETING
IF APPENDICULAR ABSCESS LESSTHAN 5 CM– USG GUIDESD
ASPIRATIONANDTUBE DRAIN
MORETHAN 5CM—OPEN DRAIN
IF APPENDICULAR LUMP Ochsner-Sherren regimen

47. Appendectomy is the only curative treatment
operatedwithout unnecessary delay for the time-
consuming or expensive investigations.
Open appendectomy is time tested.
 Laparoscopic appendectomy , introduce by Semm in 1983,
has struggled to prove its superiority over the open
technique.
In different studies, laparoscopic appendectomy has
claimed to reduce postoperative pain, length of hospital
stay, analgesic doses and surgical associated complications.

48. Antibiotic Therapy
•should include broad-spectrum gram-negative and
anaerobic coverage.
•For nonperforated appendicitis, ciprofloxacin, 400 mg IV,
and metronidazole (Flagyl), 500 mg IV; or ceftriaxone, 1g IV,
and metronidazole, 500 mg IV; or ampicillinsulbactam, 3g IV
monotherapy.
• For perforated appendicitis, broader spectrum antibiotics,
such as piperacillintazobactam, 4.5g IV, cefepime, 2 g IV, or
imipenemcilastatin, 500 mg IV. Methicillin-resistant
Staphylococcus aureus (MRSA) coverage is not typically
needed to treat appendicitis but may be considered if the
patient has previously known MRSA colonization

49.  Appendix mass.
Generalized peritonitis.
 Pelvic peritonitis.
Frozen pelvis.
Intestinal obstruction.
 Paralytic ileus.
Sub phrenic abscess.

50. Severe adhesion/ Difficult to separate
the part.
Bloody and dangerous to operate
Chance of Fecal fistula
Max chance of iatrogenic injury

51. Ochsner (1901) proposed nonoperative management for the appendix mass,
followed by interval appendectomy 6-8 weeks after successful conservative
management
 Make the limits of mass using a skin pencil.
NPO. A nasogastric tube should be passed .
 Intravenous fluids
 Maintain input output chart.
 Intravenous antibiotic therapy started.
Temperature and pulse rate should be
recorded 4-hourly .

52. Clinical improvement is usually evident within 24—48 hours at
which time the nasogastric tube can be removed and oral fluids
introduced.
 Failure of the mass to resolve should raise suspicion of a
carcinoma or Crohn’s disease
 Using this regime approximately 90 per cent of cases resolve
without incident.
 It is advisable to remove the appendix usually after an interval
of 6—8 weeks.
 Clinical deterioration or evidence of peritonitis is indication
for early laparotomy

53. RISING PULSE RATE
RISINGTEMPERATURE
 INCREASING or SPREADING ABDOMINAL PAIN
INCREASING SIZE OF MASS
VOMITING or COPIOUS GASTRIC ASPIRATE

54. Incidence 1/1500 pregnancies.
most common non-gynecologic surgical emergency
 evaluation is a bit confusing because nausea and vomiting can be incorrectly
attributed to the morning sickness.
Tachycardia is normal thing.
Fever a common finding in appendicitis is often not present in pregnancy
Leukocytosis (12000cell/ml) is common in pregnancy. However left shift is always
abnormal.
Appendectomy during pregnancy is indicated in a pregnant patient as soon as the
diagnosis of appendicitis is suspected. A negative appendectomy carries a risk of
fetal loss of up to 3%, but fetal demise rates reach 35% in the setting of perforation
and diffuse peritonitis

55. Delayed diagnosis common especially in very young ones.
Perforation rate is 50% in infancy.
lack of history and altered physical examination. 50% of
children lack of migration of pain to RLQ, 40% will not have
associated anorexia and 52% will not have rebound tenderness
 In infants and young children the position of caecum is not
fixed as it is mobile most of time.
Incidence of perforation and post operative morbidity are high
in children due to underdeveloped omentum, malnourishment
or less developed immune system.

56. • Lack of abdominal muscles laxity may hide the clinical
signs. Clinical picture may simulate with subacute
intestinal obstruction which delay the final diagnosis.
• Chances of perforation is 30% in the patients more than
60 years old because of low immune system.

57. • local signs are masked in the obese patients so the
diagnosis is more dependent on the detail
investigations like ultrasound or CT scan.
•There may be technical difficulties in operation.